CLEVELAND — Just about 16 months after the small Eastern Ohio town was thrust into the national spotlight, the National Transportation Safety Board has finished its investigation into how a train derailed in East Palestine, spilling toxic materials onto the ground and sending hazardous chemicals into the air.
The NTSB had already determined a bearing on one of the railcars overheated, causing an axle to separate and the train to crash before catching fire. Officials then decided to blow open five tank cars and burn off the vinyl chloride that was inside, something the board says was likely unnecessary while noting that those who made the call said didn't have all the information they needed.
On Friday, the NTSB released its full final report, totaling 216 pages and giving further detail on the investigation and its findings. The board also issued more than 30 new recommendations it says could have helped before, during, and after the derailment.
The recommendations include creating a database of bearing failures to help address risk factors, as well as one directing the Norfolk Southern Railway to revise the company procedures to immediately provide emergency responders with an accurate copy of train contents, something the board claims the railway delayed doing in the leadup to the toxic release. The NTSB also determined post-derailment hazards people were exposed to were at least partly caused by Ohio's insufficient training requirements for volunteer firefighters, and laid out recommended training for dealing with hazardous materials.
The release of the report follows a $600 million class action lawsuit settlement with Norfolk Southern aimed at providing money for injuries and damage to properties in the area. Attorneys said only 22 of the almost 2,000 households in the village opted out, and the settlement is still awaiting final approval.
Following the report's release, Norfolk Southern announced it had endorsed the NTSB's recommendations, saying they "align with safety initiatives currently underway at the railroad designed around the principles of accident prevention, mitigation, and response." NTSB Chair Jennifer Homendy also personally visited railway headquarters in Atlanta to discuss the findings.
"We have a deep respect for Chair Homendy and the important work of the NTSB. We appreciate her leadership, willingness to collaborate with us on next steps, and direct engagement with our operational leaders," Alan H. Shaw, president and CEO of Norfolk Southern, said in a statement. "Norfolk Southern and the NTSB share the same goal when it comes to safety. We're committed to taking action that addresses their recommendations and to becoming the gold standard of safety for the industry."
A full list of the new recommendations can be found below:
To the Secretary of Transportation
- Require the Federal Railroad Administration to issue regulations for inward-facing recorders that include image and audio recordings as recommended by the National Transportation Safety Board in R-24-10 and R-24-11. If necessary, obtain legislative authority to act on this recommendation. (R-24-1)
To the Federal Railroad Administration
- Research the effectiveness of current bearing defect detection systems, identify minimum standards to protect railroad personnel and the public, and make public the results of this research. (R-24-2)
- Use the results of the research described in R-24-2 to develop and establish minimum requirements for bearing defect detection systems, including criteria for bearing alert and alarm thresholds and maximum distances between wayside detectors. (R-24-3)
- Establish requirements for the installation, inspection, and maintenance of wayside bearing defect detectors to protect the reliability of these devices and improve the safety of railroad operations. (R-24-4)
- Use the results of the research described in R-24-2 to develop and establish rules governing railroads’ operational responses to bearing alerts and alarms. (R-24-5)
- Monitor the progress of the Association of American Railroads’ (AAR) action on R-24-20 and use your regulatory authority to ensure that the AAR addresses weaknesses in its tank car service equipment approval process. (R-24-6)
- Distribute the public versions of your 2007 vent and burn reports to emergency responder associations, including the International Association of Fire Chiefs, the International Association of Fire Fighters, and the National Volunteer Fire Council. (R-24-7)
- Update and re-publish your 2007 vent and burn reports to include clear instructions to consult the shipper when considering a vent and burn, more comprehensive guidance on what products are candidates for a vent and burn along with what chemical and other hazards may result, and an updated process flow chart incorporating lessons from the East Palestine vent and burn; the re-published reports should identify the questions an incident commander should ask when considering a vent and burn, distinguish the meaning of the answers, and identify the resources necessary to make an informed decision. (R-24-8)
- Make the updated versions of the 2007 vent and burn reports described in R-24-8 available to emergency responder associations, including the International Association of Fire Chiefs, the International Association of Fire Fighters, and the National Volunteer Fire Council. (R-24-9)
- Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash and fire protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. If necessary, obtain legislative authority to act on this recommendation. (R-24-10)
- Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. If necessary, obtain legislative authority to act on this recommendation. (R-24-11)
To the Pipeline and Hazardous Materials Safety Administration
- Require that placards be able to survive fires and accidents and remain legible during such emergencies long enough to fulfill their functions as described in the Emergency Response Guidebook. (I-24-1)
- Obtain the necessary legislative authority and accelerate the deadline for removing specification DOT-111 tank cars from flammable liquids service. (R-24-12)
- Establish a tank car replacement schedule whereby non-pressure tank cars in any hazardous materials service must meet or exceed the safety standards of the DOT-117 specification; if necessary, obtain legislative authority to act on this recommendation. (R-24-13)
- Revise the definition of high-hazard flammable train to account for differences in survivability between tank car specifications and to include hazardous materials other than flammable liquids, such as combustible liquids and Division 2.1 flammable gases, that can contribute to cascading hazardous materials releases; if necessary, obtain legislative authority to act on this recommendation. (R-24-14)
- Distribute the Federal Railroad Administration’s most current guidance on the vent and burn method to emergency response agencies by referencing it in the next edition of the Emergency Response Guidebook. (R-24-15)
To the state of Ohio
- Amend your firefighter training statute and revise your volunteer firefighter certification standards to meet the NFPA 1010 standard for professional firefighters. (R-24-16)
To the Columbiana County Emergency Management Agency
- Adopt a policy to, upon receipt of a train consist, immediately provide it to the incident commander and all appropriate response agencies and departments. (R-24-17)
- Update your Emergency Operations Plan, Hazardous Materials Response Plan, and Hazard Mitigation Plan, as appropriate, with lessons learned from the East Palestine derailment and fire, including, at a minimum, coordination among response agencies, communications, requests for and distribution of the train consist, staging and availability of equipment and other resources, and training for emergency responders. (R-24-18)
To the Association of American Railroads
- Develop a database of bearing failures and replacements and make it available to railroads, regulators, and investigators to help determine and address failure risk factors. (R-24-19)
- Revise the Manual of Standards and Recommended Practices, M-1002, Specifications for Tank Cars, to establish criteria and procedures for manufacturers of tank car service equipment to demonstrate compatibility of pressure relief devices and other Association of American Railroads-approved service equipment with intended ladings. (R-24-20)
- Revise the definition of key train in Circular OT-55 to designate as a key train any train containing tank cars transporting hazardous materials that do not meet the DOT-117 standard. (R-24-21)
To the National Volunteer Fire Council
- Identify barriers to adequate fire and emergency response training for volunteer firefighters, particularly for situations where hazardous materials are present, and publish actions states, municipalities, and the private sector can take to provide the flexibility necessary for volunteer firefighters to obtain training. (R-24-22)
- To the International Association of Fire Chiefs, the International Association of Fire Fighters, and the National Volunteer Fire Council: Advise your members of the circumstances of the East Palestine derailment and fire, identify fire departments whose personnel are not trained to the NFPA 1010 standard for professional firefighters, recommend that these departments adopt training that meets this standard, and inform them of funded training opportunities available through private, state, and federal programs. (R-24-23)
- Advise your members of the circumstances surrounding the vent and burn at East Palestine, the importance of obtaining information from the shipper when considering a vent and burn, and the availability of federal guidance on when the vent and burn method may be appropriate. (R-24-24)
To The Chlorine Institute
- Review and revise Pamphlet 171 to ensure that its safety messages about vinyl chloride monomer polymerization in tank cars are accurate and adequately support determining whether a rail accident poses a risk of polymerization. (R-24-25)
- Review and revise your Chlorine Emergency Plan training and verification programs to ensure that Level 3 contractors possess or can obtain enough technical knowledge of vinyl chloride monomer (VCM) to accurately assess and respond to chemical hazards like polymerization during a VCM incident. (R-24-26)
To the American Chemistry Council and The Chlorine Institute
- Advise your members of the circumstances of the East Palestine derailment and fire and the need for shippers to ensure their expertise is communicated to and shared with the full incident command. (R-24-27)
To Norfolk Southern Railway
- Review and revise your procedures to immediately provide emergency responders with an accurate copy of the train consist upon becoming aware of an accident. (R-24-28)
- Update your submissions to the Pipeline and Hazardous Materials Safety Administration’s Incident Database to accurately reflect the cause of package failures following the East Palestine derailment. (R-24-29)
- Adopt policies to ensure that your emergency response contractors keep detailed records of information used to make decisions involving hazardous materials, and share this information with shippers, relevant chemical associations, and other entities that provide hazardous materials guidance. (R-24-30)
- Develop a policy to ensure that the expertise of manufacturers and shippers of hazardous materials involved in transportation accidents or incidents is communicated to your on-scene representatives and contractors and shared with the full incident command. (R-24-31)
To Oxy Vinyls, LP
- Update the safety data sheet for vinyl chloride monomer (VCM) to accurately reflect the potential risks of VCM and the hazards that increase such risks. (R-24-32)
- Develop a policy to ensure that expertise on chemicals manufactured and offered for transportation by Oxy Vinyls is communicated to and shared with the full incident command during transportation accidents or incidents. (R-24-33)